Rhode Island docs alarmed by subpoenas they link to EHRs

In recent days, process servers have delivered subpoenas charging doctors at a Rhode Island hospital with medical misconduct — mistakes reported by the clinicians themselves that didn’t injure any patients but were meant to draw attention to risks in their EHR system.

The episode has upset the doctors and their colleagues, who say the state health department’s punitive response could frustrate voluntary reporting of medical errors, which contribute to tens of thousands of deaths each year in the United States. EHR safety researchers concur, saying that penalizing doctors for self-reported mistakes like this sends the wrong message.

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“Anyone punishing individual providers for these events is punishing the wrong thing,” says Jason Adelman, chief patient safety officer at New York-Presbyterian Hospital. “These are system issues, not the provider being reckless. The focus should be on things like EHR usability and safety.”

The subpoenas, sent to at least four emergency room doctors at Rhode Island Hospital in Providence, deal with X-rays and other scans mistakenly ordered by the doctors. Such errors are common because EHR screens are complex, and it’s easy to click on the wrong icon or patient name, say experts on EHRs.

“We have frequent reports of wrong-side errors,” said Lorraine Possanza, director of the Partnership for Health IT Patient Safety at the ECRI Institute, which is dedicated to improving patient safety.

There seems to be no record of how frequently health departments punish physicians for such errors. Adelman and another usability expert said that while they weren't familiar with the details of the Rhode Island episode, such enforcement is generally unwarranted.

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Rhode Island Hospital has been under a consent decree with the state since June over four mistaken radiological procedures. They involved a mammogram, heart X-ray and invasive angiogram ordered in error on three patients. The fourth was a vertebroplasty — injection of cement to fix a cracked vertebra — on the wrong vertebra. The decree requires the hospital to report any near-misses or other patient safety risks.

The decree does not name the physicians; the doctors who received the subsequent subpoenas — for scans ordered on the wrong side of a patient's body, rather than the wrong patient, except in one case — declined to speak with POLITICO. However, a colleague read most of one letter to a reporter.

The letter cited “incompetent, negligible or willful misconduct in the practice of medicine” including “rendering of medically unnecessary services” that “fail to conform with standards.” It stated the Department of Health would be ordering a hearing into the physician’s activities “forthwith.”

Health department spokesperson Joseph Wendelken would not comment on the subpoenas, but said the investigations were required by law.

“For health care facilities to ensure patient safety, they must be able to accurately identify patients at all times,” he said in a release. “We consider wrong site procedures and identification errors to be ‘never events,’ meaning they should never occur.” When they do, physicians legally must report them, and “investigations are conducted,” Wendelken said.

Gita Pensa, a physician in the emergency department who also teaches medicine at Brown University, went on Twitter last week to express frustration over the subpoenas. "Physicians have been willingly self-reporting near misses or errors, often but not always related to EHR entry, to the DOH," she tweeted. "And instead of working with those docs to target pain points, the DOH has begun individually targeting these MDs with threats of fines."

There has also been disagreement with the consent decree's stipulation that clinicians in the emergency department keep no more than one patient’s record open at a time on a computer screen, doctors at the hospital said. Medical authorities often view the one-screen policy as the safest practice, Possanza said, but some recent research indicates that may not be true in an emergency room, where physicians have to handle and monitor many patients at a time.

The Rhode Island Hospital’s emergency department has been under particular pressure recently because of the closure of a nearby hospital and its emergency room. Doctors say it is easy to make certain computer errors in a stressful ED — and the typical emergency physician’s shift involves 4,000 mouse clicks.

Physicians at the Rhode Island Hospital are committed to working with public health to enhance patient safety, Pensa said, but "to punish mouse-click errors with fines and loss of licensure seems disproportionate."

Everyone is deeply committed to patient safety, but “constables [process servers] deliver summons for criminal acts,” added her colleague, Gary Bubly. “To put this on the same level seems absurd and outrageous.”

Wrong-side errors are “unbelievably frequent” and need to be addressed, but not by punishing doctors, said Raj Ratwani, scientific director of MedStar’s National Center for Human Factors in Healthcare. A study he took part in at four hospitals — two each using Epic and Cerner EHRs — found error rates for diagnostic image orders ranging from 16 percent to 36 percent. “Wrong-side” errors were among the most common.

“Provider and vendors have to come together to talk about these issues and solve them. But what cannot happen is to blame the provider for errors that are promoted by the design of the system," he said.

Adelman’s research shows that “wrong person” orders are also common. He designed a computer program that reports each time a physician in a hospital system retracts an order to one patient, then gives the same order to another. At Montefiore Hospital, he captured 7,000 such instances in a single year. When researchers telephoned a sample of the physicians who made these reorders, they found that more than three-quarters were done to correct wrong orders.

It’s not clear how often such errors go through, but Adelman said they are likely common, because studies in which computer alerts were added to prevent them showed dramatic improvements.

Rhode Island Hospital spokesperson David Levesque said the hospital was committed to continual improvement of its processes. The health department’s actions have “done nothing to impact our transparency” which “remains a point of pride and is unwavering,” he said.